Telma Grandt Credit Card Authorization

CREDIT CARD AUTHORIZATION & INSURANCE INFORMATION
You do not have to complete this section if:

You pay Telma Grant, P.T. for services rendered after each visit.

All Direct Billing patients are required to provide a valid credit card to keep on file. If your insurance does NOT pay 100% of the submitted fee, any outstanding balance will be charged to your credit card we have on file.

In the event of a missed cancelled appointment with less than 24 hours' notice, your card will be automatically charged our full current fee for that appointment.

Credit Card Authorization: In the event of a missed or cancelled appointment with less than 24 hours' notice, your card will automatically be charged our full current fee for that appointment.
Card Type

VisaMasterCardVisa DebitAmerican Express
Cardholder Name as shown on card
First 4 numbers
Middle numbers
Last 4 numbers
Expiration Date (mm/yy)
CVC
By signing below, I hereby authorize Telma Grant, P.T. to charge my credit card above for any outstanding amounts owing on my account. I understand that my information will be securely saved on file for future transactions on my account. I further understand that I may cancel this authorization with two (2) weeks' notice by contacting Telma Grant, P.T. in writing at the address below. This authorization will remain in effect until it is cancelled.
By checking this box, I opt out of providing my credit card information and will be paying any outstanding fees onsite at Telma Grant, Physiotherapy.

Please check
Cardholder's Name
Cardholder's Signature

Clear
Patient Signature

Clear
IF OBTAINING SERVICES VIA INSURANCE COVERAGE, PLEASE COMPLETE THE FOLLOWING
Extended Health Carrier #1: Name of Insurance Company
Name of Insured (First & Last Name)
Date of Birth of Insured (yyyy/mm/dd)

YearMonthDay
Date
Policy Number
Group Number
Identification Number
Extended Health Carrier #2: Name of Insurance Company
Name of Insured (First & Last Name)
Date of Birth of Insured (yyyy/mm/dd)

YearMonthDay
Date
Policy Number
Group Number
Identification Number
Should be Empty:

CREDIT CARD AUTHORIZATION & INSURANCE INFORMATION